P.O. BOX 1603 WINDSOR, ONTARIO N9A 0B6
CUSTOMER SERVICE CENTRE 1-855-264-2174
AUTHORIZATION FORM FOR POST-CATARACT SURGERY
AND PROSTHETIC EYEWEAR
SECTION I - MUST BE COMPLETED IN FULL BY THE PATIENT/GUARDIAN
Birth Date
/ /
Plan Member Name
Plan Member IDPatient Name
Telephone No Street Address
Do you have any other Group Insurance coverage that may include these services as benefits? Yes No
If Yes, please provide Insurance Company name
If other coverage is RBC Life, indicate Plan Member ID
SECTION II - MUST BE COMPLETED IN FULL BY PHYSICIAN
Ophthalmic disease or condition:
For cataract patients, please state the date of surgery:
Lens Implant?
Ye s No//Left Eye
Day MonthYear
Lens Implant? Ye s No//Right Eye
Day MonthYear
The following prosthetic eyewear is required. (Please include prescription details):
Physician's Phone Number Physician's Name (please print clearly)
DateOriginal Physician's Signature (stamp not accepted)
THE COST, IF ANY, OF OBTAINING THIS INFORMATION IS AT THE EXPENSE OF THE PATIENT/PLAN MEMBER.
I am authorized by my spouse and/or dependents to disclose and receive information about them that is used for these purposes. I understand that this information may be
seen by the cardholder.
By signing this claim form and/or submitting actual receipts, I agree that the information provided is complete and accurate. I understand that the information provided by me
to RBC Life about myself and my dependents, will be used by RBC Life for claims adjudication and any other services necessary in the administration of our benefits which
may include the exchange of information with other parties to administer this benefit claim.
I further authorize RBC Life to obtain and exchange information with other parties, such as health practitioners or insurers, in order to confirm the accuracy of the submitted
claim(s) information. In the event of suspected fraudulent activity pertaining to claims submitted on behalf of myself and/or my dependents, I acknowledge and agree to the
disclosure of this information to relevant parties, such as the Plan Sponsor, regulatory and law enforcement agencies.
All claims must be submitted within 12 months of the date of service (unless otherwise stated in your benefit plan documentation).
Authorization Form for Post Cataract Surgery & Eyewear EN (Rev. 2018-12) PCAT
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